Day of Injury StudyDay of Injury Study2005-20062005-2006

Schools Insurance Authority

Co-Presenters:Co-Presenters:Martin Brady, Director, SIADennis Chandler, DAY-1 SystemsDebra Russell, WC Manager, SIA

SIA BackgroundSIA Background

Joint Powers Authority (JPA) Self Insured-Self Administered Administers workers’ compensation,

property & liability & prevention services

Staff CA Comp

Study of Schools Insurance Authority (SIA) workers’ compensation program.

Nurse “First Call”/Structured Return to Work Program implemented in 2000.

SIA represents 34 school districts, 19,500 employees in several counties in northern California.

Day of Injury StudyDay of Injury StudyPERI Funded Research PERI Funded Research

Comparative data analysis within industry and similar programs in CA.

National data on RN “first call’ telephonic reporting.

Develop a best practices manual for injury reporting, medical management and return to work

Day of Injury StudyDay of Injury Study

Day of Injury Day of Injury

““Controlling the workers’ Controlling the workers’ comp line of scrimmage”comp line of scrimmage”

Comp & FootballComp & Football

Team SportTeam Sport

Involves strategiesInvolves strategies

Employer is always plays defense.Employer is always plays defense.

Focus on controlling the line of Focus on controlling the line of scrimmage, day of injury.scrimmage, day of injury.

Holding the offense to no gain or short Holding the offense to no gain or short gain plays.gain plays.

RE-THINK YOUR CURRENT SCHEMERE-THINK YOUR CURRENT SCHEME

It’s All About Xs & OsIt’s All About Xs & Os

High Tech… High TouchHigh Tech… High TouchGame PlanGame Plan

What is the impact of using a nurse “first call” process to :

Employees?Supervisors?Claims management,

frequency/severity?Litigation?Medical Providers?Return to Work?

DAY of INJURYDAY of INJURY

The most important The most important play to execute.play to execute.

The employer’s response on the day of injury

significantly determines the nature, duration, cost and

eventual outcome of a claim.

Three Distinct Processes:

injury reporting & notification

assessing & managing the medical treatment process

return to work.

Day of Injury Day of Injury

Time is MoneyTime is Money

18%

30%

45%

Increased Claim Cost

COST OF LATE REPORTINGThe Hartford Study, 2000

3-D Column 1 1-2 weeks 3-4 weeks >4 weeks

Medical-Legal Event

Notification process

Data collection of facts to determine cause and claim compensability.

Medical situation/triage assessment.

Shared information to all primary stakeholders.

Injury ReportingInjury Reporting

Injury Reporting- NotificationInjury Reporting- Notification

“Invite the call” philosophy. TLC approach by intake RN. Comprehensive data gathered on the day of

injury by RN. Better claims decisions on compensability.

Effective medical channeling to occupational providers in spite of employee’s right to pre-designate treating physician.

Nurse “First Call’Nurse “First Call’

Telephonic ReportTelephonic Report

Injury report telephonically to Occupational RN.

Medical triage to preferred providers. Immediate return to work in modified duty

with pre-identified tasks (>100 modified duty options)

Ongoing RTW case management integrated with claims management.

Nurse “First Call”Nurse “First Call”

Structured Return to Work ProgramStructured Return to Work Program

Claims examiners & RN assigned to district.

Balance/interface of claim & medical goals.

RN–RTW Coordinator continually develops provider relationships, attends significant medical appointments with employee.

SIA’s Utilization Review (UR) program.

Claims Management Claims Management

Promotes communication at the onset of an incident between all parties. Litigation dropped 65%.

RN viewed as an employee advocate. Claims data: how, when, where, is more

complete & detailed. Within minutes the simultaneous processes

of claims management, medical treatment and return to work are engaged.

Nurse “First Call”Nurse “First Call”

Study FindingsStudy Findings

Telephone reports-averages 1450 incidents

(calls) annually. 40% of reports are RN self-care or report

only, not resulting in a claim. 30% of claims are classified medical

only/restricted duty due to immediate return to work in modified duty within 3 days in CA.

42% of claims are medical only. 28% of claims result in lost time/indemnity.

SIA 5 Year ResultsSIA 5 Year Results

1589 15771526

15001403

594562

662600

564

995 1015

864908

839

184174210

254

163

811 841

654654

676

303

215

235231 247

Incidents RO/RN Claims Indemnity MO MO-RD

W.C. Incidents & Claims / Types Comparison

3-D Column 1 2001 2002 2003 2004 2005

During the last 3 years, 1826 injury reports

were handled as RN Self-care/Report Only. 94 % of those incidents remained as RN

Self-care/Report Only (no further medical treatment) after 90 days.

Top three nature of injury categories were: strain/sprain, bruise/contusion, & laceration.

RN First Call ResultsRN First Call Results

26% of all calls were classified as Medical

Only/Restricted Duty. i.e. Claims with medical restrictions, back to

work within 3 calendar days. In a review of the past 3 years of MO/RD

claims, 92 % of those claims remained as a Medical Only claim after 90 days.

RN First Call ResultsRN First Call Results

First Year PerformanceFirst Year Performance Schools Insurance Authority, SacramentoSchools Insurance Authority, Sacramento

First Year Evaluation, 2000 vs. 1999 34% decrease in all claims. 44% decrease in indemnity claims. 46% decrease in total paid. 37% decrease in incurred costs. 1,589 incidents reported, 995 claims filed,

37% of all incidents did not result in opening a claim.

First Year PerformanceFirst Year PerformanceRedwood Empire Schools Insurance Group, Redwood Empire Schools Insurance Group,

WindsorWindsor

First Year Evaluation, 2004 vs. 2003 Total Incurred costs decreased 42%. Total paid costs decreased 20%. 871 incidents reported, 503 claims filed,

42% of all incidents did not result in opening a claim.

148 claims were placed in modified duty within the first 3 days to avoid an indemnity lost time claim.

RN “FIRST CALL”

Systematic return-to-work decision process.

Immediate response to employee disability using RTW Coordinator.

Utilizes planned or pre-identified RTW options .

Structured Return to Work

Structured Return to WorkStructured Return to Work

Formal mod. duty program at all districts. Goal: Fully engage RTW within 3 calendar

days to avoid indemnity claim. RTW Coordinator case manage all mod duty

claims until RTW full duty resolved. Program requires ongoing efforts to keep

program viable at site levels.

Employer’s RoleEmployer’s Role

Prompt reporting using Nurse Line Set a return to work expectation through

policy and training. Develop RTW options (plan) in all major job

classifications subject to injury claims. Maintain close contact with employee, RTW

Coordinator and claims examiner.

Temporary Work AssignmentTemporary Work Assignment

Tasks might be . . . Part of existing job Supervisor assistance Administrative; special projects Maintenance/p.m., benchwork,

cleaning Inventory/sorting/labeling/ordering Quality; visual tasks Safety/hazard inspection Training Ongoing or periodic/seasonal

Temporary Work Assignment

JOB TITLE: Shop Tasks

SUMMARY: Performs a variety of light tasks within maintenance/electrical shop. task can include sorting parts, labeling, bin straightening, filing paperwork, painting, cleaning/painting light fixtures, assisting regularly assigned personnel in benchwork tasks as available.

HOURS AVAILABLE: 8 daily

Unified School District.

Essential Job Function Essential Job Function AnalysisAnalysis

Equipment & Tool Repair TechnicianJob DescriptionJob Title: CustodianDistrict: The Best USD

Return-to-Work ProcessReturn-to-Work Process

Work Injury

Employee/Supervisor Call Nurse

Report InjuryTriage MedicalComplete ReportImmediate notification/reports to all parties

Nurse Directs/channels Employee to

Medical Treatment

Physician completes work status reportEmployee returns work status report to employer.

Employee/Supervisor & RTW Coordinator

Review work status reportAssign modified duty/TWAComplete RTW agreement

Monitor Employee’s Progress to Full Duty